Best Practices for Working with Commercial Payers
Medicare continues to reduce payments, forcing home health agencies to look for other ways to maintain revenue and profits. One alternative source of revenue to consider is commercial payers. To be successful when working with commercial (private insurance) payers your agency will need to be organized and well prepared. Here are some recommendations to help you get started.
Know Your Market Find out which insurance companies operate in your area. Typically, these should include Medicare Advantage providers, Medicaid HMOs and straight commercial care companies.
Contracting with Commercial Payers Generally speaking, you are required to contract with the insurance companies in order to do business. In addition, some companies will require Joint Commission or CHAPS accreditation to be a contracted provider. Although you may be eligible to contract with the insurance companies, that does not mean that the insurance companies have to admit you to their network. Many times, admission is determined by specialty, regional need and demand. If you offer special services that may set you apart from other home health or hospice agencies, be sure to let them know!
I Am a Contracted Provider. Now What? There are a number of differences between handling Medicare and commercial care. It is imperative that your staff is trained on what is needed to take on patients with private insurance. While most Home Health & Hospice agencies have a certain comfort level with Medicare processes, it is much more variable in commercial care. Each insurance company requires different details for authorization and reimbursement. Being knowledgeable in these details will make a big difference in ensuring that your agency is accurately paid for the services that you delivered.
Authorizations Most insurance companies require pre-approved authorizations for care. Authorizations should be acquired before you see any patient. Seeing a patient without prior authorization could lead to non-covered services.
Authorizations usually cover a set period of time and a certain number of visits. Your agency must keep track of this information. If your patient will require more services, you must contact the company for further authorization, and provide justification in writing for the additional services. If you go beyond your authorized dates or provide more visits than authorized, be prepared for those services to be non-reimbursable. This can be an adjustment for field nurses that are accustomed to adding PRN visits for Medicare patients.
Electronic Billing Paper claims can be a nightmare. They can easily get lost and can be difficult for your agency and the insurance company to keep track of. As a result, most private payers require or, at a minimum, prefer electronic billing. Some offices have as many as 64 different payers that have to be set up to be billed correctly. Typically, each one will require an NPI number, tax ID number, etc. In addition, many commercial payers do not pay episodically. Visits and services are individually authorized and billed. More often than not, co-pays and/or deductibles are required. Given these challenges, it is important that you have knowledgeable commercial billers to handle your commercial claims. Billers with Medicare experience won’t necessarily get the results your agency is looking for.
Follow-Up is Critical Most agencies are accustomed to following up on Medicare claims. It’s a pretty straightforward process. However, it’s not so simple with commercial insurance companies. Every payer has its own set of rules and your agency is responsible for knowing and ensuring that you follow them. Follow-up is critical in order to keep positive cash flow for your agency. However, this can be very time consuming when dealing with several companies. Effective follow-up requires billers who are well trained and familiar with each step of the process. Due to the complexity of the billing process for commercial and managed care companies, most agencies choose to electronically bill through third party vendors or “clearinghouses.” These companies can help your agency stay on top of the regulations and setup required by each payer, providing the necessary claim follow-up and on-going coordination as needed.
To learn more about how HEALTHCAREfirst can help you establish and easily manage billing for commercial payers, contact us at email@example.com.